How About a ‘Time Out’ for the Surgical Environment, Too?


We observed National Time Out Day on June 12, an annual event created by the Association of periOperative Registered Nurses (AORN) that reminds us of the important “time out” protocol in the operating room. 

The time out period occurs just before a surgical procedure and allows the team to take a moment to review at minimum the patient’s identity, the correct site for operation and the procedure to be done. 

Among all the hustle and bustle of the operating room, this is a time where everyone pauses, is on equal footing and ensures the quality of patient care.

There is another factor at the center of patient safety and care that sometimes does not get as much attention as the time out: the physical environment in and around the operating rooms. 

The operating room is a heavily regulated area in an already heavily regulated sector. The risk is high. If something goes wrong, it is very important that the surgical environment is completely prepared and ready for the team to respond. 

That is why regulating bodies like the Joint Commission (JCAHO) and The Centers for Medicare and Medicaid Services (CMS) create standards for patient care and safety.

And the hospital environment is a big part of meeting those standards. The CMS standards and certifications, 42 CFR § 482.41, sets guidelines for hospital facilities, for example:

d) Standard: Facilities. The hospital must maintain adequate facilities for its services.

(1) Diagnostic and therapeutic facilities must be located for the safety of patients.

(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality.

(3) The extent and complexity of facilities must be determined by the services offered.

(4) There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas.


Here are a few scenarios that emphasize how much the surgical environment impacts patient safety:

Equipment usage: Equipment technicians are responsible for setting up surgical equipment for surgeons. When hospitals get new equipment, for example a new microsurgery machine, it requires detailed calibration upon start up and various steps to complete a proper shut down. 

If done incorrectly, the machines could offer up incorrect readings and potentially harm patients. Surgery departments need a way to guarantee this is done correctly, every time, as it is likely done by a different technician each day. 

Areas outside the OR: Often, areas outside of the OR where anesthesia is administered (NORA) get less attention than they should. This makes them higher risk because a) they are often further away from the OR theaters and b) good records of what was done to maintain these areas are harder to keep.

Take, for example, a difficult airway cart stored outside of the OR; it needs to be monitored just as routinely and consistently as if it were stored inside the OR. All of the special equipment and supplies used when an anesthesiologist needs to access a patient’s airway must be checked for expiration.

Weekends: The weekend poses a huge opportunity and also huge risk. When surgeries are not ongoing, there is time to maintain the surgical environment. However, there are also fewer supervisors (often none) on duty. How do you make sure perioperative staff are accountable without an on-premises supervisor working weekends? 

When common challenges like these are not properly addressed, in some instances, hospitals can face fines related to compromising patient safety. 


Lack of Visibility

Adding to these challenges is a general lack of visibility into the processes that keep operating rooms and areas outside of the OR where anesthesia is administered (NORA) up to standards. 

Healthcare is becoming more and more digital. But it is not unusual for perioperative staff to still use paper checklists to help track environmental compliance. Or worse, they do not document anything at all. 

The problem with paper checklists is there is no accountability or visibility into whether and when individual tasks have been completed. Supervisors always have a lot going on and tracking down a paper list is usually not high on their agenda. 

Unfortunately, it is one of those things where hospitals may not realize they need a better system until regulators come knocking.

We have seen situations where regulators want to go over every event that happened (e.g. the JCAHO’s tracer methodology) leading up to and after a particular surgery in question--who cleaned the room, when were the supplies checked and so on. 

Digging through paper files to pinpoint the exact information the regulators are looking for is a painful process. And often, the information that is produced does not meet regulators’ needs.

Today, perioperative staff needs a better, more efficient way to capture all of the data related to compliance in the surgical environment; even if it is not always clinical, it is still extremely important. 

And that can be accomplished with some of the newer technology on the market, like our ReadyList Surgical solution.


The Role of Technology in Compliance

The right technology helps keep compliance within reach for surgical teams. 

  • It can support infection prevention by standardizing OR protocols related to equipment and cleaning. 
  • It can reduce risk by digitizing and even customizing safe surgical environment checklists. 
  • It can capture all the data that regulating bodies need to know like what sort of prep and cleaning happened between cases and who did it.
  • It can show regulating bodies that a process has been put in place to address a violation in question. 

Anson Daine, vice president of client services at ReadyList, shared a story with me:

“A ReadyList customer recently had a JCAHO survey. They found a deficiency related to scope processing, and JCAHO wanted some very specific intervention to make sure that the expiration dates were checked moving forward.

Within 24 hours, we enabled accountability for checking expiration dates on this equipment via ReadyList. The equipment technician used the ReadyList app every day to ensure the equipment was not expired in various storage locations.

The information collected in technology like ReadyList can very easily be presented to an organization like JCAHO to show who checked the equipment and how often.”

There are more customer stories, too-- like how ReadyList helped one hospital ensure the enclosures that housed dialysis machine connections were consistently cleaned to guarantee no contamination; or how another hospital needed help to safeguard their water systems with proper daily maintenance to prevent Legionnaires disease.

That is why technology can do so much more for hospitals today than just provide visibility. Technology can also help elevate the surgery department’s operational processes to deliver better surgical care, and stay on top of mounting regulations.

I believe that the time out period before an operation is a critical time for surgical teams to pause for a moment and help ensure the best possible outcome. Let us put the same focus on our surgical environments to ensure the best possible quality of care.


Brian Herriot is a hospital operations leader and CEO of ReadyList, Inc. ReadyList software ensures fully operational surgical environments to help clinicians focus their time on patients.

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